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The first of the four horsemen of the apocalypse was the crowned rider on the white horse bringing pestilence. Now that we have our very own modern ‘crowned’ pestilence in the form of the coronavirus many feel afraid and think that we may be living in the end of days. As we spend our lives locked in our houses watching the news report the grim daily body count of the dead it is difficult not to think “How will this end? Will I get coronavirus? Will I die?”

I don’t know the answers to the first two questions but I do know the answer to the third. The answer, as it always has been, is “Yes; you will die”. I don’t know if it will be through Covid19 or in some freak blender accident but I know it will happen.

This assurance is the only true thing we know. We all know that in the end we all die. Indeed throughout our development as a species it has been the prospect of our death that has guided us. Religious beliefs have looked at this and allowed us to use death to put our lives in context. Religions have helped us live while always and everywhere we are in the presence of death. Our awareness of our death is the defining point of our life – we have to ensure we set our house in order before we shuffle off our mortal coils.

I fear that over the past few generations, in our increasingly secular society, we have lost our familiarity with death. In the UK most deaths no longer occur at home but now most people die in forms of care; hospitals or nursing homes. We now don’t have a connection with our fate. Death is something that happens to other people, something that happens to people far away in the hospice, people far away much older than me.

I noticed when watching an advert on television for life assurance just how distanced we have become. This was one of the many adverts urging the elderly to buy a policy to pay for their funeral costs to spare their family the expense. In this an older man narrates that “if the worst happens I know my family are covered”. Why ‘if‘ rather than the correct ‘when‘? If we can’t even think of death when making an advert for funeral costs we are in a sorry state. These are life assurance policies as we are assured that death will eventually occur.

But in these times of plague this inability to consider death is causing problems. People feel that they should not die. They think if they spend enough money, eat enough healthy food, take enough exercise or pay enough taxes then they should be alright. There is a feeling that death is avoidable if we know what to do. This has lead to our rather wishful and juvenile planning regarding the lockdown.

The function of the lockdown was to “flatten the curve”, to slow the rate of infection progression so that our health care systems would not be overloaded – so that we would have unavoidable and unnecessary deaths due to lack of medical provision. It was never a lockdown to stop the virus in its tracks, it was always known that when it was eased (barring miracles) we would again have to face the virus. But hopefully, by then, we would have prepared adequately so that our health systems were ready and that we had started behaving in ways that would mitigate the virus’s spread.

It was never the plan that we would hunker down and wait for the cavalry in the form of a vaccine or treatment. Even if these occur it is not likely we will see them in the next few years and the personal and social costs of lockdown for this period of time could be even worse then the virus itself. It is inevitable that if no one is producing then a time when no one is consuming must follow. We in the developed West can’t hope that the poor abroad will continue to take the risks to attend fields and stock simply to fill our food supply chains. We should recall that, after the crowned horseman of pestilence came the next three riders- poverty, war and hell – the deaths through poverty and famine could be every bit as horrendous .

No matter how frightened we are, and I’ll admit to a fair degree of fear, we have to find ways to live alongside coronavirus, to find ways of living in the knowledge that there are things that may, at any time, kill us. It will force us to change our behaviour – saving expectantly all year to be packed into a sealed petrie dish and flown across the world (breathing the air recycled through lungs of your 200 fellow passengers) for your two week holiday may no longer seem a great way to live. Many of the long supply chains we have grown to rely upon may start to look like ever present risks. Being more self-reliant in food production, or having strong social care services, may now seem much more important priorities than lower taxes or cheaper costs when we make our political decisions.

There are many things we can do to learn how to cope with the new future. My only real fear is that is we continue with this plan of hiding until it goes away we will miss the opportunities to deal with it. My real fear is that we might ‘return to normal‘ and then we will have to restart the battle all over again.

When I received the news that I had Type II Diabetes a few years back I should really not have been surprised. I could not have claimed that I had looked after my health and should have known that decades of sloth and excess would eventually take their toll. But, despite this, it still felt like a blow especially after re-reading the medical literature and realising that I was suddenly much closer to meeting my maker than I had ever previously thought.

For the first few months this was very dispiriting. I moped around feeling sad and rueful about my earlier nonchalance about my health. Occasionally I would feel angry thinking “I gave up smoking 60 fags a day to get this !!!“, as if one step I took to look after my health should have undone everything else that would befall me. I didn’t get depressed, but I did get sad and fearful, and imagined a future being blind, impotent and without my legs (having lost these to diabetic vasculopathy). But ‘every cloud has a silver lining‘, as they say, and this fearfulness prove to be very useful; it was the fillip I needed to change my behaviour.

Since then I have walked every day, at least twice a day, and made considerable changes to my diet and lifestyle. But it is the walking that has had the biggest impact on my life. This is not primarily because it helps me control my weight, although it does, it is because of the psychological effect it has. I am fortunate to live in a corner of Wales which is very scenic. Every morning and evening I walk the same 2km loop but every day it looks that little bit different.

In the mornings the walk is a great way to gather my thoughts for the day and plan what projects will take priority. It is a time to think over the news that the radio had delivered with the morning cup of tea. The weather is the major factor on the morning walk. This is the time of day that we can often have wonderful mists which reveal the hidden glens in the landscape. It is the first time of the day I venture out, so is the time I am introduced to the weather for the day. I now meet the rain, wind or frost having spent the last 8 hours warm in bed.

Morning mists hang in the valley as the sheep and I start our day.

The evening walk is a different kettle of fish. This walk is a time for review; to look back over the day and consider how it went. This is a time to mull and compose correspondence in my head, as the dogs and I walk in the gathering darkness. The weather is less of an issue on this walk, as by know I have been outside much of the day and am well acquainted with what has been going on. On this walk it is usually the sky which is the focus. As the sun sets down behind Cader Idris we can have spectacular displays and hints at what tomorrow might bring.

Sheep and shepherd hoping that this display does promise delight

Illness and death are inevitable. As we age and get closer to the latter we usually have to learn how to cope with the former. I have been fortunate not to have been tested too much. My first proper brush with poor health has forced me to think and caused me to lead a better life than I did before. I will not always be so lucky, but hopefully whatever happens in my life it will cause me to change and I may again find some way to salvage something good from whatever befalls me. (I think tonight’s sunset was making me feel particularly mellow.)

Deaths due to drug abuse in Scotland have hit an all-time high. In 2018 1,187 people died in Scotland as a consequence of drug abuse a rise of 27% on the already frightening figures of 2017. This places Scotland in a class of its own in Europe with a level of drug-related deaths twice that of the next nearest country (Estonia). It would be difficult to underplay the size of the problem. The drug-related death rate in Scotland is now three times the size of that in the U.K. as a whole and last year more people died in Scotland from drug misuse than from the direct effects of alcohol!

The figures did unnerve me but unfortunately they did not come as a surprise. In the decade before I moved to Wales, I worked as a consultant psychiatrist in a deprived area of Scotland and had witnessed first hand the growing problem. More importantly, I had also seen the developing drug strategy which was being pursued. This policy seemed doomed to failure and almost guaranteed to increase the amount of death and injury due to recreational drug use.

The main reason for this was that the strategy in Scotland had only one string to its bow and that string was Harm Reduction. This took a number of forms including needle exchanges, methadone prescribing, safe spaces and the like. While harm reduction can be valuable it is not enough on its own unless you can reduce the harm to negligible levels (which is not going to be the case with something like drug use). The simple logic is that if you reduce the rate of harm to half of what is was before then this will look impressive, but if at the same time you triple the number of people taking the risk then you will have increased, not reduced, the total amount of harm done. The evidence is that Scotland has many, many more people abusing drugs than previously and thus as a consequence many more deaths. It is important to note that about half of these deaths involve methadone which is the prescribed opiate which was intended to reduce the harm.

More people taking these drugs leads to more deaths and a false sense of security by harm reduction strategies may compound the problem. The need is to reduce the harm, but more importantly, to reduce the usage of drugs. It is unlikely that laws against usage will make any great headway, there is little evidence that laws deter people from drug use. Indeed, there is a little evidence that illegality enhances the cachet of drugs in some groups and promotes their use. This cachet is further enhanced by our culture’s tendency to glamourize drug use; watch any late evening chat show or read any interview with a modern media star and see the use of drugs being used as a badge to garner respect. In the recent race to become the Tory party leader, and hence Prime Minister of the UK, had the unedifying spectacle of all the candidates competitively ‘confessing‘ their drug misuse in an attempt to win the youth vote.

In addition to this cultural acceptance of drug use there is the further problem that, now, drug misuse is an access route into welfare benefits. In a country, such as Scotland, with high levels of unemployment and poverty there will be some pressures to look at the problem of addictions differently – when being on the sick role as an addict could mean being prescribed opiates (methadone) by the state and receiving money in the form of Personal Independence Payments. (Addictions UK for example have a service to help secure payments when you have an addiction). The biggest problem facing those with addiction problems is securing autonomy and independence again, compounding a drug dependency with a welfare dependency will simply amplify the problem.

In an ideal society people would be free to decide on their use of drugs but also responsible for the consequences of taking them. There is little to suggest that the state will be able to make this aspect of our behaviour disappear but there is good reason to think that it has the capacity to make problems worse. Prescribed opiates are now killing as many people as illicit ones, and we have developed a large industry which lives on the backs of those trapped in cycles of dependency. The last decades have seen Scotland move to a much more authoritarian and controlling nation state. This change has important social and cultural effects and these figures showing a dreadful loss of life, and hinting at even worse disability and hurt, should act as a wake up call to the risks involved.

Jodi Picoult’s books are often the victim of some snobbery. They are seen as the cupcakes in the literary patisserie; light, airy, and fun, but hardly serious. However, there are times when what you fancy is a cupcake and you don’t want anything too serious or fancy. These are perfect for a ‘by the pool on holiday‘ or ‘last thing at night to get to sleep’ read.

This one follows the usual formula –take a moral dilemma, populate it with some stereotypes, and join it together with a narrative thread. In Lone Wolf the dilemma is turning off life support in the setting of brain injury. To be fair it does air the conflicts that exist and does show the impossibility of being dogmatic. If it had stopped at this it would have been a respectable, workmanlike, novel but it unfortunately had to include a side story of a man who went to live in the wolf pack.

This part of the book was wildly inaccurate and exaggerated and did not serve to amplify any of the points of the main story. Indeed, if anything, it made the reader think ‘if she can be as gullible on this, how accurate are her other views? ‘. Rather like finding something hard, crunchy, and out of place in your cupcake.

If you are packing a bathing suit and heading abroad this book might be a good choice, but if you are packing an overnight bag for a hospital visit perhaps not.

We had a cold start to the day this morning and we have more promised to come. Though I was not too keen on this first thing today, when I had to break all the ice from the animals’ water troughs, I am generally glad to see the season behaving more like a normal winter. The cold snap reminded me that, while I had cut and collected enough timber for fuel, I have not split enough logs nor prepared enough kindling. So now I have my weekend planned.

I saw in the agricultural diary, when I was writing our log, that the Welsh proverb of the week is “Gaeaf Glas wna Fynwent Fras“. This can be translated as a harsh or cold winter will lead to full cemeteries. It reflects early awareness, of now scientific knowledge, that winter is the most dangerous season. Indeed the 7th of January is the day of the year on which more people die than any other. Possibly reflecting two factors : the first is the winter season itself, and the second may be the ability of people to hold on or persevere until after the Christmas period – slipping off the mortal coil at a more timely point.

Gaeaf Glas literally means a blue or green winter. Although now ‘glas’ is used to mean ‘blue’, earlier the celtic languages didn’t distinguish in words between blue and green and used ‘glas’ for both colours. This is why the “dear green place is called “Glasgow”. Now, in Cymraeg (welsh) we use glas for blue and gwyrdd for green and I am not sure that this is a step forward. Sometimes I think the prior situation may have been better.

At the moment we are trying to renovate our holiday let’s kitchen and this entails choosing the colour of the doors of the cabinets. You might imagine that this is an easy task. Think of a colour you like, blue, or green, or red, and decide on that colour. But unfortunately this does not work. I have now discovered that there are bluey-greens and greeny-blues, as well as greens that are too greeny. I have been asked to look at cards and select between sage green, pale verdigris green (which is gray), soft pastel mint green or soft duck egg green (which is blue). Once we have selected an apt green for the cabinets we can then open the big book of paint colours for the splash back. I think there are over 20 blues and greens in here.

I really have no hope of contributing to this debate. Indeed I don’t know why I bother, my wife will make the decision anyway. Not only can I not distinguish between these imperceptible shade differences (Imagine being asked which you prefer “magnolia” or “almond white” or “cream” ! They are all the same). But also there is the mystery of matching to come – “Do you think this brown picks up the brown in the carpet ? Or is it too reddy brown ? I have no hope of playing this game. I don’t know the rules and I am also wired wrongly. Studies have shown that men and women differ in what colour differences they can perceive and as a consequence men and women have different colour categories and nouns.

In this area I think expansion of categories is a hindrance rather than a boon and we should start a campaign for real colours. We would permit red, blue, green, yellow, purple and orange but suggest that all the other colours are simple figments of the home-decorating and furnishing industry and banned as fraudulent advertising. Although of a libertarian inclination this is one area in which I could support some increased legislation. Think of the marital disharmony it would prevent and the number of divorces that would be avoided. Think of the errors that could be avoided day-to-day – no longer could somebody be asked to get the taupe cardigan and make a mistake and get the gray one. Bliss.

Now that I am old I have the great fortune to be able to watch afternoon television. The programmes run in the afternoon are obviously cheap fare; either rubbish to punish the unemployed, or easy nostalgia to appeal to the older viewer. These programmes are innocuous enough but I am rather worried by the type of advertisement which predominates. I don’t mind the repeated ads for stair lifts and incontinence pads. This is fair enough, my time will come when I need these things. I don’t even mind the adverts for capital release – suggesting I’m gullible enough to give over my home, and all its value, for the short term fun of a holiday or giving a gift to my children. No, these are all fine. What annoys me are the repeated funeral plan adverts.

Advert after advert tries to worry me about the cost of funerals and urges me to buy a plan now so that I don’t have to worry about it in the future. Now, to tell the truth, I never really worry about the cost of my funeral. I can be pretty sure that the one person who will not be around to worry about that bill is me ! If I have money left when I die then this will be used to pay for my funeral. If I am so short of money that I will have none left then the last thing I should be doing is spending money on my future corpse. I obviously need that money now, use the money during your life to keep life tolerable or fun. Don’t waste scare reserves on the one purchase you will certainly never be able to enjoy.

This is the thing about funerals. They are about how the people who knew you, and are still alive, decide you should be remembered. They are not your choice. Sure, if you think you are so unloved that you are going to be put out in a bin bag with the garbage then it might be better to buy a plan and avoid the ignominy. But a better plan might be to behave better, become better regarded and thus secure some positive attention following your demise.

Funerals are for the survivors to express their sadness and to celebrate the life of the departed. They should choose how this is done. If they want to have a big event with much gnashing of teeth and wailing then that is their right, likewise if they want a low key affair then that too is correct. We hope that we will be missed because we hope that we were well regarded and loved. No amount of money will sort this problem other than perhaps by how beneficent you are during your life. So if you are really keen on preparing for your death and funeral look to how you are living not to planning your funeral. Imagine the terrible scene there could be if you bought a wonderful funeral, with black horses, banks of lilies, a marble mausoleum but there was no one there because you had been so miserable during your life and so self-centred that no-one really missed you.

Don’t buy a funeral plan, make a gift to a friend, help a family member in their time of need, or make a charitable donation if you are really concerned about how people will think on you once you are gone. Think that it might just be possible that this is a scam by funeral directors to get people to pay more and earlier for their services. They play on the elderly’s guilt; suggesting that we should give up our possession now as we really shouldn’t enjoy them, and also suggesting that we are a burden and we should be very careful that we stop being a burden when we die. Really saying, make sure, when you go, you leave no mess for us to clear up, no awkward bills or planning. Tidy up and close the door after you ! Sorry, I’m not doing it, I’m using all my money wisely and hopefully generously because, as they say, there are no pockets in a shroud.

As the relentless march of time carries me ever onwards towards my demise I find, perhaps as a useful reminder, that I spend increasing times at funerals. It seems that each month I am on a pew listening to the service, recalling the life of a friend or acquaintance. Each time I am aware at how increasingly close to my age they were when they passed. I listen to the services and to the stories of the lives of my friends and find it very comforting that everyone gathers together to remember the departed and to show respect for their life.

This respect is real. It doesn’t depend on the person having done anything spectacular or unusual it is simply respect for a life well lived : a parent to brought up children, a spouse who supported their partner, a neighbour who played a part in the community. It is respect earned by living a good, normal life. However, it is not shallow respect or deference, this is respect that was earnt as it came by the passing of time. It came by being a good person day in and day out for years. It follows from raising children to their maturity. It is respect when a spouse helps through the thin times as well as the good. It is respect that is often earned in those times at the end of our lives when illness and infirmity make our lives harder. A partner who sees beyond these elderly problems and gives support and love despite them certainly deserves anyone’s respect.

We often talk of love in our teenage and early adult years when we are setting out on the road of our lives. The songs we hear are about our love being as deep as the oceans or as wide as the mountains. We will face and conquer all for the person that has conquered our heart. But how little we know. In many developed countries the average length of a marriage, until separation or divorce, is a little over 10 years. The romantic songs of our youth often profess undying love but for many a decade is the length of eternity.

At these funerals I hear the tales of marriages which have lasted decades. Stories of couples who, split by death, lived longer together than they ever did apart. Stories of children bereft of parents who have always been part of their lives. It is clear when you listen to these tales of normal life that there were good times and dark times, but the latter were faced down and defeated. It is clear that, it is the sharing of these difficulties that is important in the person’s love, probably more so than the simple sharing of enjoyment. During these years families and couples grow into each other and grow deeper in love. Like watching a vine growing over the years round a tree, in time the vine supports the weak and broken branches; were the vine not there neither would be the tree. Pleasures are important, and obviously enjoyable, but it is the facing difficulties together that tempers love and makes it stronger. The more problems you solve together the deeper is your attachment and affection.

“For age is opportunity no less
Than youth itself, though in another dress,
And as the evening twilight fades away
The sky is filled with stars, invisible by day.”
Henry Wadsworth Longfellow

A love that cannot overcome difficulties is a weaker thing, these elderly couples demonstrate that their love was so strong that, ultimately, only death could break them apart and, even then, could not break their love. These eulogies of the bereft are the love songs of the elderly and they remind us that love can last for ever. They sing not of the possibilities of love but of the proof of enduring love over time. They also remind us that working to stay together can strengthen and deepen love. We should be wary of viewing love through the eyes of the young and foolish, looking only for pleasure and joy. No-one’s life can be unalloyed joy we will all need to face difficulties, dangers and disappointments. If we have a family these dangers will be multiplied (although so will the joys). Finding someone who cares about you enough to stand by you throughout is a remarkable feat and should demand that you are steadfast in return. If both of you can do this, you will have found something the young can only sing about.

“Grow old along with me! The best is yet to be,

the last of life, for which the first was made.

Our times are in his hand who saith, ‘A whole I planned, youth shows but half;

The Learning Disability Mortality Review was published this week and it has largely gone unnoticed in the press and news. While we flaunt the successes of our health service, and describe it as the “the envy of the world“, we have ignored the fact that there is a serious problem with how the NHS treats one of the most vulnerable groups in our society. The report looked at those with learning Disability dying in NHS care and found that in about one in eight of those deaths neglect, abuse or incompetence had “adversely affected” the care that the individual had received.

The report makes harrowing and upsetting reading. It is clear that this group of people are being sold short by our health service, that they are often felt to have lives not worth saving. There are reports of staff failing to recognise the worth of the individual and thus they are discriminated against. This utilitarian view of life is very dangerous and particularly dangerous, in a system such as the NHS, where the client is not the patient but the state itself. The state will have the tendency to value some lives are more productive than others, more valuable than others, and thus worthy of more attention. This group of people find themselves at the bottom of the pile when priorities are being drawn up. When the calculus of how much someone is worth is reckoned their values – the pleasure they bring to their families, the love they express, the friendships they make – don’t weight well in the scales and they loose out.

Staff recognise this and start to behave accordingly; they care less for the patients and come to view them as obstacles in the path to giving better care to more deserving patients, and, in extreme cases, unworthy of using the resources which could be better used by someone more valuable. All of this has echoes of the film “Dasein Ohne Leben ” (“Existence without Life”), the 1942 Nazi propaganda film which was intended to soften the public’s opposition to the euthanasia, or murder, of the physically and mentally handicapped.

Although this group of people almost certainly suffer the most from this neglect they are unfortunately not alone. When I was working I was repeatedly shocked by the contempt that medical and nursing staff could express for patients with dementia seeing them as nothing more than “bed blockers” who were misusing scarce resources. Recent scandals about breast screening errors again show that ageism is still prevalent. Older women have higher risks of breast cancer but screening is avoided because it is “not worth it” in this group. Were the NHS an insurance system, as it was initially intended, then people who had been in the scheme longer, and contributed more, would expect better dividends not a scheme which rewards their involvement by reducing their entitlements.

But advanced age is not necessary to be a victim of this type of calculation. The high profile cases of severely disabled children being removed from their parent’s control causes further concern. In these awful cases, the parents asked for nothing extra from the NHS other than to get out of the way and to let them try what they could for their babies. Their hopes for their offspring were almost certainly futile but it may have helped the parents to know that they had done all that was humanly possible for their sons. But the system felt is was important, having assessed the importance of these infants lives, to stop the parents and other systems doing what the might lest they squandered resources.

When systems become too large they often become inhumane. When the patient and their family is not the focus then the system operates on economic principles of value for money. It stops being an insurance scheme to protect us form the high costs of health care, by aggregating risks, and becomes a system to ration care. In a rationing system the vulnerable groups of the disabled and elderly always loose out particularly in times of scarcity. As the NHS becomes increasingly unable to meet the demands put upon it it will start to ration ever more strictly. Then it matters not a fig, whether you paid your taxes diligently, or worked productively, or are a valued member of your family and community, if you are deemed too expensive and too unproductive then your services are going to be poor. You will get the minimum that can be offered if a callous system allow even that to happen.

Our sons and daughters, and brothers and sisters, with learning disabilities are not lesser people than us. They have every right to care and we should feel ashamed that a system what we hoped would provide universal healthcare is failing to do so for the weakest and most vulnerable of our fellow citizens.